When it comes to medical advice about sex and the heart, it is a man's world. Titles of scholarly articles are filled with double entendre, such as "Sex, erectile dysfunction and the heart: A growing problem," and are primarily about such drugs as Viagra.

Here is some advice pertaining to both sexes on the risk of having a heart attack during sexual intercourse, resuming sex after a heart attack, and the fact that men and woman may have quite different perspectives.

A review in JAMA answered the first question. For both men and women, the risk is very low, about 2 to 3 per 10,000. This risk was decreased by 45 percent more in those who were physically active in other ways besides having sex.

Anxiety has been found to be a trigger - the cardiac risk of a sexual encounter outside the boundary of an established and loving relationship is significantly higher.

The VIRGO study, done in 2014, explored the problems that can occur with sexual activity after younger adults had heart attacks. One in five acute myocardial infarctions occur in people age 18 to 55, and 39 percent of those attacks are in women. These facts led to several important findings. First, sexual activity can be safely resumed soon (within one month) after an uncomplicated heart attack if mild to moderate physical activity is tolerated. Yet, only one in three women and half of the men had resumed having sex in this study at one month.

Second, the biggest factor that prevented a return to normal sexual activity was a lack of physician counseling.

Third, a surprising finding was that almost 20 percent of heart attack survivors (men and women) reported difficulty breathing during sex in the year before their heart attack. Normal sexual physiology involves increased respiratory rates, but should not cause difficulty breathing. Who knew that this could be an early warning sign of a potential heart problem? If you experience it, see your doctor!

Another study looked at the perspectives of women on sex and heart disease. One month after a heart attack, 75 percent of women said sex was important, compared with 90 percent of men. But the need for nonsexual physical intimacy was higher for women than men.

Women tended to initiate the discussion with their doctor about when it was safe to have sex, and were more likely than men to be unsatisfied with the conversation. It was the lack of high-quality communication, rather than lack of information about safety, that was the major barrier cited by women toward resuming sex. The key finding: Cardiologists need to talk about sex with every patient who has had a heart attack before the patient leaves the hospital.

Take-home messages:

If you are in decent shape, the risk of having a heart attack during sex, even after having a heart attack, is incredibly small. If you have just had a heart attack, abstaining for 30 days is being conservative.

Getting in better shape by walking the dog or doing any kind of exercise at all will further reduce this already small risk.

Anxiety caused by cheating outside the bounds of a relationship may increase that risk.

Women and men approach this issue very differently, and there's a gender gap in patient-doctor communication.

The partners of heart attack survivors also need to be considered. The fear, more common in women than men, about the risk of causing their partner physical harm during sex needs to be addressed in this conversation.

The risk of taking medication for erectile dysfunction is small. But don't forget to call your doctor if an erection lasts more than four hours.

Dr. David Becker is a board certified cardiologist with Chestnut Hill Temple Cardiology in Flourtown, Pa. and has been in practice for 25 years. In 1993, after extensive research, Dr. Becker launched Healthy Change of Heart™, an innovative 10-week program designed to reverse heart disease and improve quality of life through diet, exercise, and stress management. Since then, thousands of patients have participated in the program, achieving significant results in improving cardiac wellness.

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